What to know
- For millions of low-income New Yorkers, access to regular dental care has long depended on whether or not they have eight critical teeth.
- A mouth with just four pairs of matching back teeth is considered “adequate for functional purposes,” according to state rules for Medicaid recipients. And those that are considered functional, no matter how many other teeth they’re missing, aren’t covered for root canals and crowns, two of the most common procedures in the field.
- Under a new legal settlement reached Monday, the New York Department of Health must drop some of its most restrictive rules for Medicaid recipients, including its longstanding “eight points of contact” policy.
For millions of low-income New Yorkers, access to regular dental care has long depended on whether or not they have eight critical teeth.
A mouth with just four pairs of matching back teeth is considered “adequate for functional purposes,” according to state rules for Medicaid recipients. And those that are considered functional, no matter how many other teeth they’re missing, aren’t covered for root canals and crowns, two of the most common procedures in the field.
Under a new legal settlement reached Monday, the New York Department of Health must drop some of its most restrictive rules for Medicaid recipients, including its longstanding “eight points of contact” policy.
The change would expand dental coverage for about 5 million people, dramatically improving oral health for low-income patients across the state, according to Belkys Garcia, an attorney for the Legal Aid Society, which brought the class action lawsuit in federal court. 2018.
“Prior to this, the Medicaid program was really just a teeth-pulling program,” Garcia said. “If you needed a root canal or a crown, the program was designed to pull your teeth instead of treating them.”
Medicaid programs vary by state, and dental care is not a federally mandated benefit. A few states, including Alabama and Delaware, do not provide dental coverage to adult Medicaid recipients, while about a dozen others offer care only in emergencies.
But states that provide the optional benefit are required to cover all medically necessary care. The lawsuit argued that New York had imposed “rigid limitations on critical services,” leading to denials of coverage for medically necessary care.
Among the plaintiffs was Matthew Antinolfi, a former New York taxi driver who had all but three teeth pulled after a mouth infection in 2010. He soon discovered his dentures had slipped, preventing him from eating.
He was told he needed a dental implant, which is not covered by the state. Instead, he chose to eat without dentures, wearing down his gums and the remaining bone in his mouth. He will now need a more complicated surgery, possibly involving a bone graft, to secure the dentures.
“If I could have dealt with it right away, I wouldn’t have lost as many bones as I did,” Adinolfi said.
The settlement removes the ban on dental implant coverage. Denture replacement will also be deemed medically necessary. The new rules will take effect 90 days after the court approves the settlement agreement.
The Department of Health is committed to providing “comprehensive health coverage” to all Medicaid recipients, spokesman Cort Ruddy said in a statement. “This settlement recognizes the importance of oral health and reaffirms the state’s commitment to these individuals.”
The health department did not immediately respond when asked how much the expanded care would cost.
Studies have shown deep racial and economic disparities in oral health, and efforts to address disparities in adults have shown limited progress, according to a report from the US Centers for Disease Control and Prevention.
The change in New York’s rules comes just as millions of adults on Medicaid nationwide will lose dental coverage when the national public health emergency COVID-19 expires later this month.
The Legal Aid Society worked with two law firms, Willkie Farr and Gallagher and Freshfields Bruckhaus Deringer, on the action.
